In Compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all
positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status,
non-job related disability, or any other protected group status.

To be read and signed by applicant

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hearby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contated, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review Information provided by previous employers;

Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

If Yes, please explain. Conviction of a crime is not an automatic bar to emloyment-all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, please explain.

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding
3 Years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in interstate or interstate commerce shall also provide an additional 7 years’
Information on those employers for whom the applicant operated such vehicle.
(NOTE: List emloyers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER

Name

DATE

From

To

Where You Subject to the FMCSRs* While Employed?

Yes

No

Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40?

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle
used to transport hazardous materials in a quantity requiring placarding.

*The Federal Motor Carrier Safety Regulations (FMCSRs) Apply to anyone operating a motor vehicle on a highway in interstate
commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is
designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity
requiring placarding.